an unusual masquerade of community acquired pneumonia left side unilateral pulmonary edema

KEY WORDS: Consolidation, pneumonia, pulmonary edema, respiratory failure An unusual masquerade of community acquired pneumonia: Left-side unilateral pulmonary edema Akashdeep Singh, Gup

dietary and pharmacological noncompliance The patient was successfully managed with decongestive therapy and non-invasive mechanical ventilation

CASE REPORT

A 76-year-old man, a known case of dilated cardiomyopathy, presented to the Emergency Department with severe breathlessness and cough productive of blood stained sputum of 2 days duration His compliance with diet and medication was poor

At admission, he was orthopnic, had an RR of 40 bpm, BP

of 140/100 mmHg, HR of 110/min, and body temperature

of 37.2°C His neck veins were full, and there was pedal edema Respiratory system examination revealed impaired percussion note and fine crackles in the entire left hemithorax Cardiac auscultation revealed S3 gallop and

a high-pitched, holosystolic murmur at apex radiating to the left axilla

Laboratory investigations revealed a TLC of 14000/μL with 75% neutrophils Chest radiograph showed left-sided airspace disease with cardiomegaly [Figure 1] and electrocardiogram showed LBBB His creatinine 1.4 mg/dL, sodium 140 mEq/L, potassium 4.0 mEq/L, B-natriuretic peptide 1200 pg/mL, creatine kinase isoenzyme MB 6.1 ng/mL, and troponin I 0.14 ng/mL

INTRODUCTION

Pulmonary edema is usually bilateral, but unilateral

pulmonary edema (UPE) can also be seen in clinical

practice UPE can masquerade pneumonia, as it may

present with similar clinical and radiological findings

Furthermore, UPE may represent a diagnostic challenge

to the physician and is considered in the differential

diagnosis after treatment failure This misdiagnosis can

result in inappropriate management, unnecessary cost,

and the respective risks related to the untreated potentially

life-threatening condition Discrimination between

UPE and pneumonia is difficult at times and involves

careful analysis of history, physical findings, and specific

diagnostic tests like B-type natriuretic peptide (BNP),

procalcitonin (PCT), and echocardiography Most cases of

UPE reported in the English literature have been on the

right side Here, we have described the case of a 76-year-old

man who developed acute left-sided UPE resulting from

The diagnosis of pneumonia is clinical, based on the history of lower respiratory tract symptoms, physical, and/or radiographic signs of consolidation Several diseases such as congestive heart failure, pulmonary embolism, and chemical pneumonitis may present with similar symptoms, signs, and chest radiographs, thus delaying the definitive diagnosis and initiation of appropriate treatment Unilateral pulmonary edema (UPE) is a rare clinical entity that is often misdiagnosed at first as a focal lung disease We have presented an unusual case of left-sided UPE in a 76-year-old man who developed acute heart failure resulting from dietary and pharmacological noncompliance The patient was successfully managed with decongestive therapy and non-invasive mechanical ventilation

KEY WORDS: Consolidation, pneumonia, pulmonary edema, respiratory failure

An unusual masquerade of community acquired pneumonia: Left-side unilateral pulmonary edema

Akashdeep Singh, Gupreet Singh Wander 1

ABSTRACT

Address for correspondence: Dr Akashdeep Singh, Department of Pulmonary and Critical Care Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India E-mail: drsinghakashdeep@gmail.com

Case Report

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DOI:

10.4103/0970-2113.120617

Differential diagnosis of pneumonia versus UPE was kept

He was started on oxygen, diuretics, low molecular weight

heparin, GTN infusion, anti-platelets, statins, intravenous

antibiotics (cefepime and azithromycin), and

non-invasive mechanical ventilation Echocardiography done

revealed a reduced global left-ventricular ejection fraction

(LVEF 35%), and a large eccentric mitral regurgitation

jet reaching the left pulmonary veins His serial CRP

and PCT were low His cultures (sputum and blood) did

not grow any organism, and therefore antibiotic were

discontinued on day 4 With decongestive therapy, there

was significant clinico-radiological improvement Repeat

chest radiography done after 48 h of admission showed

significant resolution of the unilateral opacities [Figure 2]

The patient was discharged uneventfully on day 5 of

hospitalization, and presently he is on a regular follow-up

with the Cardiology Department

DISCUSSION

Acute cardiogenic pulmonary edema is a life-threatening

condition with high mortality Clinically, it is characterized

by rapid onset of dyspnea, tachypnea, tachycardia,

and severe hypoxemia The radiological hallmark of

cardiogenic pulmonary edema is bilateral symmetrical

opacities in the perihilar area resulting in the classic

“butterfly shadow” or “bat’s wing” appearance

UPE is a rare clinical entity that presents diagnostic

challenges and is often misdiagnosed at first for

pneumonia, aspiration, or alveolar hemorrhage

Cardiogenic UPE is a rare clinical entity occurring in

about 2% cases of congestive heart failure.[1] UPE has

been reported after congestive heart failure,[2] mitral valve

insufficiency,[3] and fluid overload from various causes.[4,5]

Unilateral oedema with ipsilateral pathology has been

reported with prolonged lateral decubitus position,[6] rapid

thoracentesis,[7] after acute upper airway obstruction,[8]

pulmonary contusion,[9] talc pleurodesis,[10] pulmonary vein occlusion,[11] and congenital or surgical systemic to pulmonary shunt (e.g., Blalock-Taussig shunt).[12]

Unilateral oedema with perfusion abnormality in the contralateral lungoccur withunilateral pulmonary embolism,[13] unilateral hypoplasia of pulmonary artery,[14]

Swyer-James syndrome, and unilateral emphysema/bullae However, severe MR (organic or functional MR) is the main cause of UPE.[1]

Most cases of UPE associated with heart failure affect

the right lung In a study by Attias et al., UPE was

right-sided in 89% of cases and left-right-sided UPE was infrequent, representing only 0.2% of all cardiogenic pulmonary edema cases.[1] Left-sided UPE as a consequence of mitral

regurgitation is rare Tomcsanyi et al., reported a case of

left-sided UPE due to an eccentric mitral regurgitation, which complicates an inferior acute myocardial infarction.[15]

UPE is often misdiagnosed at first for other causes of unilateral alveolar and interstitial infiltrates, especially pneumonia, resulting in delay in initiating optimal

treatment Choi et al., demonstrated an average delay of

4–5 days in initiating appropriate treatment of CHF in patients with cardiogenic UPE.[16] Furthermore, patients with UPE have a higher risk of mortality, 6.9-fold higher, than patients with bilateral pulmonary edema, and delay

in adequate treatment of UPE may be one explanation for this increased mortality.[1]

BNP is of great help in differentiating between acute

pulmonary edema of cardiogenic or non-cardiogenic origin The possibility of heart failure is very low when BNP levels are <100 pg/ml (negative predictive value 90%), while the possibility of heart failure is very high when BNP levels are >500 pg/ml (positive predictive value 90%).[17]

In our case, the patient was diagnosed to have left-sided pulmonary edema, despite the unilateral pulmonary

Figure 1: Chest radiograph showed left-sided patchy airspace disease

with cardiomegaly Figure 2: Chest radiograph done 48 h after decongestive therapy

shows resolution of the opacities

infiltrate on the basis of absence of fever, organic MR,

negative cultures, high level of B-natriuretic peptide, and

low PCT and CRP levels The indexed case had very rapid

disappearance of left-sided opacities, following optimal

and aggressive treatment of congestive heart failure

UPE is an uncommon presentation of cardiogenic

pulmonary edema Asymmetrical opacities on a chest

skiagram usually have a respiratory cause, but UPE must

be kept in mind, especially in patients with compatible

clinical presentation Early and aggressive treatment

should be initiated promptly to avert bad prognosis

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How to cite this article: Singh A, Wander GS An unusual

masquerade of community acquired pneumonia: Left-side unilateral pulmonary edema Lung India 2013;30:344-6.

Source of Support: Nil, Conflict of Interest: None declared.

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